Here’s the good news: this is one type of gender pay difference that is easy to fix
According to a recent report from the New England Journal of Medicine, women primary care physicians generate 10.9% less revenue from office visits compared to men physicians despite spending 2.6% more time in the office with patients. While women physicians had a lower volume of patient visits, they spent almost 16% more time with each patient. During this additional time, researchers found that women physicians placed more medial orders and discussed more medical diagnoses and preventive care during office visits than men physicians.
This begs the question: why are women not being paid for their additional labor? According to the study, the answer seems to be that men physicians are simply better at billing for their work than women physicians, including billing based on time.Also, women physicians in procedural fields like radiation oncology were also less likely to bill for “lucrative procedures” than men physicians.
Here’s the good news: this is one type of gender pay difference that is easy to fix. There are two choices: First, women physicians can opt-out of a broken healthcare system that rewards short visits and high billing codes and enter into a Direct Care model. Alternatively, you can invest some time into learning how to work the system to your advantage. As a woman family physician, I’ve done it both ways, and while I advocate for the former (Direct Primary Care has been a life-changer for me), I was also able to out-earn many of my men colleagues in traditional practice by learning how to outsmart the system.
Here are my top tips on how women physicians can close the gender pay gap in a relative value unit (RVU) model practice.
Unlike attorneys, a physician’s billing clock only starts ticking when we have a face-to-face encounter or formal telemedicine session with a patient. Phone calls and e-mails reviewing lab results are not compensated. Medication refills, prior authorizations, insurance forms, disabled parking passes, jury duty excuses, school medical excuses — physicians are not paid for any of these services, even though they may take a considerable amount of time, with family physicians spending nine hours per week on uncompensated labor.
The reality is that in a fee-for-service insurance model, the only way to be fairly compensated for work as a physician is to see patients in the office. So, rather than calling or emailing lab results, schedule your patient to return for a visit to review them together. If a patient calls with questions, concerns, or clarifications, ask them to schedule an office visit. After all, an office visit is almost always the best way of evaluating your patient and providing the best medical care.
In addition, every time a form appears on your desk to be filled out, forward it to your office scheduler with a note to bring the patient in for an office visit. Doing paperwork while the patient is in the office not only allows you to bill for your work, it also saves you time — the chart is ready for you, the patient can directly answer many of the questions that need to be addressed on the form, and the doctor has the opportunity to address medical concerns that relate to the paperwork, such as changing a medication or requesting prior authorization for a medication that is medically necessary but not covered on the patient’s insurance.
Don’t miss out on quick, easy visits like urinary tract infections or minor skin infections because you lack schedule availability. With the current system of coding, a minor issue that you can attend to in five minutes is reimbursed just a bit less than a visit that takes you 30 minutes and loads of cognitive effort. The best way to ensure availability is to block several slots per day for urgent, acute care visits. These can be dispersed throughout the day or reserved during certain intervals, such as the last hour of the morning or the end of the day.
It is simply impossible to attend to every single problem that a patient has in one visit, along with addressing preventive care, although it’s clear from the NEJM study that women physicians certainly try their best! We need to accept that we can’t do it all, and instead, prioritize the most important issues and ask our patients to schedule follow-up visits. This can be difficult, as many of us are “people pleasers” and fear letting down our patients. We also worry about patients’ schedules and causing an additional copay. However, we need to accept that one of the keys to quality health care is developing a long-term relationship with a patient. Having the same physician over time reduces patient mortality by allowing more opportunities for us to explore our patients’ health and intervene over their lives. Remember: You cannot address a lifetime’s worth of problems in a single 15-minute visit, and you must not expect this of yourself.
It’s especially important to schedule frequent follow-ups with patients who have serious chronic health conditions or underlying psychological conditions like anxiety disorder. Some of these patients are prone to showing up without appointments, often in crisis, and can severely impact the day’s schedule. By scheduling frequent follow-up visits, you eliminate the same day, “urgent” appointments. Frequent visits are reassuring to patients, many of whom fear abandonment. It also helps to tell your patient how much time you have scheduled for them at their appointment, to help them prioritize what is most important.
When families come into the office together, ‘surprise’ visits can cause a strain on the visit. You know the situation. You’re in the exam room seeing a well-child when mom points to a sibling and says: "Can you just check his brother’s throat?He’s been complaining that it hurts." Or you’re seeing a husband and wife together but just one is scheduled for an appointment. Inevitably, the conversation turns to a concern about the other spouse’s health.
This creates a dilemma. While you could ask the ‘add-on’ patient to schedule an appointment to discuss their issues, it may be quicker and easier to address the problem directly. However, don’t forget to capture a billing code for the work that you did. Even if you spend minimal time, you are likely to garner enough information to capture at least a level 99212 code for the work you did.
Also, don’t forget to ensure that you properly bill for wellness visits and screening codes. The most efficient way to do this is to create a template or form. I also recommend including the dates of your last preventive screening in your Problem List, where you can see at a glance what services are due.
Women physicians must take the time to learn how to code accurately to be fairly paid for their work. Often, physicians underestimate the amount of work that we are doing and tend to undercode. Yes, it seems unnecessarily complicated, but a few steps can make it easier. First, remember that billing codes are driven by the extent of medical decision making. If a patient has a new problem, requires additional evaluation like blood tests, or needs a prescription medication, they are likely going to warrant a higher level of service. If a patient has a life-threatening condition, you need to call 911, or you are going to really worry about the medication you must prescribe, then the level of service increases to the maximum. To ensure that you are checking all the right bullets, consider posting a chart of coding requirements for history, physical, and medical-decision-making next to your computer.
As a physician, you should never be coding a 99211, which is a nursing code for an evaluation ordered by a physician, like a blood pressure check. If you take a quick look at a patient and make a straightforward recommendation, you have earned at least a 99212.
Don’t forget to use time-based documentation when you spend the bulk of your visit “counseling or coordinating care.” For example, time-based coding will likely come into play with the patient who comes in severely depressed or has a stack of forms for you to fill out. While you don’t have to do lots of documentation for history or physical, you do have to document the time spent, both total and counseling time, and details on the counseling/coordination of care activity.
Our current system rewards interventions more highly than cognitive services. Primary care physicians should take advantage of this to serve patients. The key to success is having proficiency in your procedural skills and developing an established protocol for each procedure that you perform in the office.
If you didn’t have the opportunity to practice many procedures in your residency, there are many courses at continuing medical education conferences. Another way to gain expertise is to find a physician mentor that does procedures in the office. Of course, be sure to know your limitations – when in doubt, refer the patient to the appropriate specialist.
Before performing a procedure, break it down into individual steps. Create an organized list of supplies and actions required. Be sure that you have all the proper equipment ahead of time and get the best equipment that you can afford. Include a plan for follow-up and a patient handout if necessary for after the procedure. Using your prepared protocol, your medical assistant should be able to quickly ready the exam room for the procedure. Also, make sure that your patients know that you offer office procedures so they can contact you if they need help, rather than visiting an urgent care or specialist.
Rebekah Bernard is a family physician and the author of How to Be a Rock Star Doctor. She can be reached at her self-titled site, Rebekah Bernard, MD.